A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

Apply pressure just above the insertion site.

Monitor the pulse distal to the insertion site.

Obtain vital signs.

Reinforce the dressing.

Answer and Explanation

The Correct Answer is A

A.   This is the first step to control bleeding and prevent further blood loss.
B.   Monitoring the distal pulse is important, but controlling bleeding takes precedence.
C.   Vital signs can wait momentarily until the bleeding is under control.
D.   Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority.

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Correct Answer is D

Explanation

A. Stevens-Johnson syndrome is a severe, rare, and potentially life-threatening reaction that can occur as a hypersensitivity reaction to certain medications. However, it is not typically associated with morphine use.
B. Morphine is more commonly associated with hypotension rather than hypertension. Therefore, while monitoring for changes in blood pressure is important, hypertension is not a primary concern with morphine administration.
C. Morphine use is not typically associated with prolonged wound healing. However, it can cause respiratory depression, which can indirectly affect wound healing by reducing tissue oxygenation.
D. Morphine is a potent opioid analgesic that can cause respiratory depression, leading to bradypnea (slow breathing) or even respiratory arrest. Monitoring respiratory rate is crucial when administering morphine to detect signs of respiratory depression early and intervene promptly.

A. Kyphosis B. Constipation C. Enuresis D. Facial twitching

Correct Answer is D

Explanation

A) Kyphosis, or curvature of the spine, is not typically an urgent concern in sickle cell anemia.
B) Constipation can occur but is not typically an urgent complication.
C) Enuresis, or bedwetting, may be a concern but is not typically an urgent complication.
D) Facial twitching could indicate neurological involvement or a stroke, which is a serious complication of sickle cell anemia and requires immediate attention.

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A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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